This document discusses several types of pelvic osteotomies used to treat developmental dysplasia of the hip. The main osteotomies covered are the Salter single innominate osteotomy, Pemberton acetabuloplasty, Steel triple innominate osteotomy, Chiari medial displacement, and Ganz periacetabular osteotomy. Most pelvic osteotomies require remodeling of the bone and are not as useful in older children over age 8. Careful matching of the procedure to each patient's individual case is needed. The more complex osteotomies have a steep learning curve for surgeons.

1. Pelvic Osteotomies
Dr. Dale Williams

2. DDH Management Overview
• 0-6 months
– Pavlik harness
• 6 Months – 2 years, failed Pavlik
– Closed reduction ± tenotomies, hip spica cast 3 months
• 2-3 years, failed closed reduction
– Open reduction
• 3+ years
– Open reduction ± femoral osteotomy ± pelvic
osteotomy

3. Overview
• Four general types of osteotomies
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Single innominate (Salter)
Acetabuloplasty (Pemberton)
Triple innominate (Steel)
Shelf (Chiari)

4. Salter Single Innominate
• Age – 18 months – 6 years
• Requires concentrically reduced hip
– Open reduction at same time possible
– Iliopsoas and adductor tenotomies often required
• Covers antero-lateral acetabular deficiency
– Up to 15o of acetabular index corrected

5. Salter
• Anterior approach to acetabulum
– Exposing inner and outer ilium
– Expose hip capsule if reduction needed
– Transverse osteotomy just above acetabulum
• G. sciatic notch to AIIS
– Rotate on pubic symphysis antero-lateral
– Hold correction with bone graft wedge & K-wires

6. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

7. Pemberton Acetabuloplasty
• Age – 18 months – 10 years
• Requires reduced hip
• Decreases acetabular volume (small head)
– Remodeling of acetabulum required
• Corrects >15o AI
• Reduces antero-lateral acetabular defects
– Cuts altered to cover more anteriorly or laterally

8. Pemberton
• Anterior Approach - Exposure as for Salter
– Cut inner and outer table with small osteotome
• Anterior – transverse plane, lateral – lateral incline
– 1cm above AIIS, staying 1 cm above capsule
– Do not cut through to sciatic notch
– Lever through cut until coverage acceptable
• Levers on tri-radiate cartilage
– Hold correction with bone graft wedge

9. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

10. Dega Acetabuloplasty
• Similar to Pemberton
• Larger posterior hinge
– Hinges on horizontal tri-radiate limb
• Less inner table osteotomized
– More inner table – more anterior coverage
– Less inner table – more lateral coverage

11. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

12. Albee Acetabuloplasty
• Similar to Pemberton
• Outer table only osteotomized
– Cut into cancellous bone to tri-radiate cartilage
– Lever outer table laterally, hinging on triradiate cartilage
– Hold open with bone graft
• Provides some posterior coverage
– Cerebral palsy

13. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

14. Steel Triple Innominate Osteotomy
• Age – Skeletally mature
• Requires congruent hip joint
• Divides ilium, ischium and superior ramus
– Acetabulum rotationally free
– Indicated when other osteotomies not possible
• Rotates to cover any acetabular defect

15. Steel
• Multiple incision technique
– Posterior between gluteal and hamstrings
• Allows osteotomy of ischium
– Anterior freeing medial attachments
• Allows Salter and superior ramus osteotomy
– Rotate acetabulum as desired
• Avoid externally rotating
– Bone graft wedge, fix as per Salter type

16. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

17. Chiari Medial Displacement
• Age – skeletally mature
• Salvage operation only
– Used when no other osteotomy possible
– Possible with subluxed hip
• Covers well laterally
– Anterior and posterior augmentation may be
necessary
• May be useful in other conditions
– Coxa magna, OA in dysplasic hips

18. Chiari Medial Displacement
• Anterior approach – as per Salter
– Identify superior extent of capsule
– Cut from AIIS to notch following capsule curve
• Angle osteotome 10-20o cephlad
– Displace distal fragment medially 50-100%
• Ensure complete head coverage
• Leg abduction, hinges on pubic symphysis
– Secure with hardware

19. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

20. Staheli Shelf Procedure
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Age – older child to skeletal maturity
Salvage operation
Indicated for non-concentric hips
Augments supero-lateral deficency
– Slotted bone graft over capsule deepening
acetabulum

21. Staheli
• Anterior approach, outer wall exposure only
– Identify superior acetabular edge
– Create slot 1cm deep along edge, angled cephlad
– Remove 1 cm cortical strips from outer table
• Insert into slot, cutting at desired lateral overhang
• 2nd layer inserted lengthwise
• Use remaining to fill in above slot edge
– Hold in place with reflected fascia and adductors

22. From: ATLAS OF PEDIATRIC ORTHOPAEDIC SURGERY, 3rd Edition

23. Ganz Periacetabular Osteotomy
• Age – adults
• Osteoarthritis 2o to lateral acetabular defect
– Decreased coverage increases articular surface
stresses leading to early OA
• Easily combined with trochanteric osteotomy
• Technically extremely difficult

24. Ganz
• Anterior approach – lateral wall exposed
– Superior ramus osteotomy, Salter osteotomy
• stopping 1 cm from posterior edge
– Angle 120o along posterior acetabular edge
• Stop 1cm from inferior edge
– Cut along postero-inferior acetabular border
into obturator foramen
– Insert Shantz pin superior as a lever
– Fix with screws, insert bone graft as needed

26. Summary
• Most require remodeling
– Not as useful in older child (age>8)
• Careful match of procedure to patient
needed
• Steep learning curve for more complex
types